Dr. Shapira's Chicago Headache Blog

An article by Jeanetta C. Rains1 and J. Steven Poceta gives an opinion paper on the relation of sleep to headache. They feel that headache is linked to a wide variety of sleep disorders that may impact treatment results and headache management.

They believe that after standard diagnosis of headache a sleep history should be collected according to headache problems. Initally they state that you should rule out sleep apnea in patients with headaches on awakening. I agree and have frequently said that the two main causes of morning headaches are TMJ disorders, Sleep Apnea and Bruxing. The NHLBI of the NIH published a report "Cardiovascular and Sleep Related Consequences of Temoporomandibular Disorders" Morning headaches can also be caused by jaw clenching but newer evidence relates clenching to awakenings by sleep disordered breathing.

They believe that cluster headaches, chronic migraine and chronic tension-type headache should have sleep apnea ruled out as a cause. I believe that looking at the neuromuscular system to evaluate patients for TMJ disorders, muscle disorders and trigeminal nervous disorders related to the bite is also essential. Neuromuscular Dentistry is a method that has been shown to be "overwhelmingly successful according to Dr Barry Cooper and as published in Cranio Journal.

If there are signs and symptoms of sleep apnea they Rx polysomnography and treatment with CPAP. While CPAP is effective I feel patients with headaches and sleep apnea would be much better served by combining treatments by utilizing an intra-oral apnea appliance that will also help decrease headaches of trigeminal orgin, or almost all types of headaches. Studies with oral appliances for headache treatment show a minimal 50% improvement in the majority of patients. They do not advocate suspending regular headache treatment when treating apnea but many of the patients treated with oral appliances report complete relief of headaches. CPAP can also be effective but 60% of patients reject it and it causes negative side effects in a significant number of patients who use it leading to discontinuation of CPAP and/or poor compliance.

The authors stated that use of oral appliance, surgery and weight loss are untested displaying a suprising amout of ignorance about the current parameters of care for treating sleep apnea that considers oral appliances to be a first line of treatment for mild to moderate sleep apnea and an alternative for severe apnea when CPAP is not tolerated. The percentage of patients that do not tolerate CPAP is the same for mild, moderate and severe sleep apnea patients.

The authors reported "patients with migraine and tension-type headache, insomnia is the most common sleep complaint, reported by one half to two thirds of clinic patients." They did not specify it is was sleep onset insomnia or maintenance of sleep insomnia.

The authors also stated "All headache patients, particularly those with episodic migraine and tension-type headaches, may benefit from inclusion of sleep variables in trigger management."

I believe it in incumbent on physicians and dentists treating headaches be acutely aware of the effect of sleep disorders on headache.

They should also be aware that psychiatric disorders and depression frequently occur in chronic pain patients as a direct result of the chronic pain.

Treatment of sleep disorders and headache with a combination of a neuromuscular daytime orthotic and a n intraoral sleep apnea appliance or use of a 24 hour orthotic is "overwhelming successful" as published in Cranio Journal.

Labels: atypical migraine, chronic daily headaches, cluster headache treatment, cluster headaches, neuromuscualr dentistry, oral appliances, SLEEP APNEA, sleep disorders, tension-type headaches

Osteopathic manipulation and Chiropractic manipulation both treat headaches by changing input into the trigeminal nerve much like neuromuscular dentistry does. The article states: " Pathologic findings in the neck constitute an accepted etiology or precipitant for headache. Osteopathic manipulative treatment may reduce pain input into the trigeminal nucleus caudalis, favorably altering neuromuscular-autonomic regulatory mechanisms to reduce discomfort from headache." The pathology in the neck is addressed to reduce pain (nociceptive) input into the trigeminal nucleus caudalis. The easiest and most direct method of reducing nociceptive input into the trigeminal nerve is a diagnostic orthotic followed by definitive long term treatment. The beauty of neuromuscular dentistry is that correcting the stomatognathic/ trigeminal system leads to auto correction of many neck problems.

The reason that NUCCA and A/O (atlas orthogonal) chiropractic is so effective when used in conjunction with a neuromuscular orthotic is that the chiropractic and/or osteopathic adjustments hold when the underlying masticatory pathology is adressed.



J Am Osteopath Assoc. 2007 Nov;107(10 Suppl 6):ES10-6.
Diagnosing and managing migraine headache.
Mueller LL.

University Headache Center, University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine, 42 E Laurel Rd, University Doctors Pavilion, Ste 1700, Stratford, NJ 08084-1354, USA. SOMPhysicians@umdnj.edu
Comment in:

J Am Osteopath Assoc. 2008 Apr;108(4):191; author reply 191, 214.
Headache is one of the chief complaints among patients visiting primary care physicians. Diagnosis begins with exclusion of secondary causes for headache. More than 90% of patients will have a primary-type headache, so diagnosis can often be completed without further testing. Although tension-type headaches are the most common kind of headache, patients with this type of headache rarely seek treatment unless occurrence is daily. Migraine, which affects more than 30 million people in the United States, is the most common headache diagnosis for which patients seek treatment. Migraine is a chronic, often inherited condition involving brain hypersensitivity and a lowered threshold for trigeminal-vascular activation. Intermittent debilitating attacks are characterized by autonomic, gastrointestinal, and neurologic symptoms. Migraine results in a marked decrease in a patient's quality of life, as measured by physical, mental, and social health-related instruments. Accurate assessment of a patient's disability will guide physicians in prescribing appropriate modes of therapy. However, migraine remains underdiagnosed, and patients with migraine remain undertreated. A comprehensive treatment approach to migraine may include nonpharmacologic measures, as well as abortive and prophylactic medications. Informing patients about realistic treatment expectations, possible delayed efficacy of medications, and avoidance of caffeine and overuse of medications is critical for successful outcomes. Management of migraine is a dynamic process, because headaches evolve over time and medication tachyphylaxis may occur, necessitating changes in therapy. Pathologic findings in the neck constitute an accepted etiology or precipitant for headache. Osteopathic manipulative treatment may reduce pain input into the trigeminal nucleus caudalis, favorably altering neuromuscular-autonomic regulatory mechanisms to reduce discomfort from headache.

PMID: 17986672 [PubMed - indexed for MEDLINE]

Labels: A/O, atlas orthogonal, atypical migraine, cluster headache treatment, Migraines, neuromuscualr dentistry, NUCCA, nucleus caudalis, spenopalatine block TMJ, TMD, trigeminal nerve